Freedom

Freedom involves Risks.

Freedom is frequently

Dangerous,

Noisy,

Inefficient,

Disorganized,

Irresponsible,

And Selfish

(…but there is a down side….)

And Yes Virginia, It is all Fun and Games until somebody puts an eye out….

(Thenit’s time to call 911)

Ever since I began working EMS, people have always asked one question. “What is the worst call you ever ran?” That is a tricky question for several reasons. First, there are just so many different types of really bad calls, depending on how you judge or categorize them. Many of my associates would call them good calls, meaning that they were challenging or may have provided excellent opportunities to utilize their best skills. Aside from challenging vs. boring, the worst calls would be categorized into something like:

The bloodiest, or the most disgusting, in terms of common standards.

The most heart wrenching or emotionally disturbing.

The Strange, The Weird, and The Peculiar.

The most dangerous or challenging rescue operations.

The Stuff People Put up their Asses.

The bloodiest calls would be anybody vs. a train. The train always wins. Trains literally deconstruct their victims. One or two passengers inside a car hit by a train can provide more than enough gore and goo to completely coat the inside of the vehicle with the insides of the passengers. Same thing goes for anyone who falls more than three stories, especially onto concrete. Not that it matters much, as the decelerating injuries onto any surface, even water, can explode the internal organs. Eviscerated bowels and brain matter are especially disarming, although the most initially disarming thing I ever saw was a prolapsed uterus secondary to a motor vehicle vs. pedestrian accident. Nevertheless, for Bloody/Gory/Disarming all at once, you can’t beat any suicide involving a twelve-gauge shotgun.

The most heart wrenching would have to be pronouncing a fifteen year-old boy dead after he shot himself in the chest with a shotgun. The family discovered him in the bathroom upon return to their home. Our job was to obtain an ECG strip, and write a report on our findings in order to pronounce him officially DOA. In the ten or so minutes I was in the house, his family was in the living room with several detectives. Just remembering hearing their grief makes me choke up even now, twenty years later.

The strangest and weirdest calls usually involved drag queens, although I do not say that in derogation. My previous life experiences involving The Arts, Music, and Theater as well as Education provided me ample opportunities to experience and observe Gay, Lesbian, Transvestite, Transgender, and Cross-Dressing individuals in a much more unguarded and “natural” state, where acceptance and understanding were considered de rigueur. Indeed, in those settings I frequently felt like an intruder into their world, like Jane Goodall among the chimpanzees. If I was going to learn and prosper within the setting of a foreign and often closed culture, I would have to check my prejudices at the door if I intended to be tolerated and accepted as an unobtrusive observer. That having been said, there were still occasions within the framework of rescue operations, when I was unprepared for the sort of surprises that a career in EMS has the opportunity to provide, like…

The strangest and weirdest calls usually involved drag queens, although I do not say that in derogation. My previous life experiences involving The Arts, Music, and Theater as well as Education provided me ample opportunities to experience and observe Gay, Lesbian, Transvestite, Transgender, and Cross-Dressing individuals in a much more unguarded and “natural” state, where acceptance and understanding were considered de rigueur. Indeed, in those settings I frequently felt like an intruder into their world, like Jane Goodall among the chimpanzees. If I was going to learn and prosper within the setting of a foreign and often closed culture, I would have to check my prejudices at the door if I intended to be tolerated and accepted as an unobtrusive observer. That having been said, there were still occasions within the framework of rescue operations, when I was unprepared for the sort of surprises that a career in EMS has the opportunity to provide, like…

“Med Three to XXXXXX Hospital Medcom.”

“This is XXXXXX Hospital; go ahead.”

“Show us in route to your facility with an unconscious, unresponsive female in her mid-thirties who was involved in a high-speed, head-on motor vehicle crash with significant front-end deformity to both vehicles and marked intrusion into the passenger compartment. Seat belts were in use and both airbags deployed with mild to moderate contusions and abrasions to the face secondary to the airbag. Patient is negative for obvious deformities, frank hemorrhage, or compound fractures…Uhhh…(long vocalized pause, slightly off mike)…What?…(another long pause)…Update to follow shortly….”

“Correction. We are in route to your facility with a mid-thirties MALE involved in the previously described motor vehicle crash….”

In the course of conducting the secondary exam and survey, which involves removal of clothing to inspect for occult injuries, it was discovered that the patient had a little something extra to present for which the medic was just not prepared. Of course it did not change the treatment or level of care which the patient received, at least not a few miles north of Key West…I wouldn’t care to speculate about Utah or Montana, however.

In the Sixties and early Seventies, when mind-altering drugs like LSD, mescaline, peyote, or psilocybin mushrooms were commonly used, and marijuana use was almost assumed, the more untoward reactions could frequently be managed by counseling in a quiet, non-threatening atmosphere. The occasional violent or overtly psychotic reactions were usually managed by Thorazine administration, but were relatively rare. I remember. I was there in the thick of it. By the Eighties and Nineties, Cocaine, Crack, Ice, PCP (Angel Dust), Heroin, Ketamine, Quaaludes, Rohypnol (Rufies), MDMA (Ecstasy), THC, Valium, Halcion, Amyl Nitrate, and many other legal, illegal, or even designer drugs were readily available everywhere. Their use in the Gay community was pandemic.

Drag in itself involves a great deal of fantasy, imagination, and varying degrees of the Willing Suspension of Disbelief, especially in Gender Dysmorphic individuals who believe that they are awoman trapped in the body of a man. The Club Kids of the Eighties carried costume to the extreme, even masquerading as aliens or animals. Drag has everything to do with State of Mind. When you stop and think about it, there isn’t that much difference between a Civil War re-enactor and a drag queen. One uses black powder and the other uses face powder. One is primarily concerned with muzzle loaders, while the other employs both muzzle loaders and breech loaders freely. Both involve fantasy, masquerade, and costuming. For the Civil War re-enactor, the drug of choice would invariably be alcohol, (preferably after the performance), but with drag queens, you had to add the possibility of unknown quantities of unknown medications with almost limitless possibilities for synergy and/or cross-reactions, and it could make for some of the most bizarre and unnerving encounters and conversations you can imagine, at least in the Eighties and Nineties.

One particular evening, we were dispatched to a report of a naked woman walking down the median strip on Los Olas Boulevard in Fort Lauderdale. Upon our arrival, police officers transferred custody of a somewhat delirious recently post-operative transgendered individual intent upon showing “her” goodies to anyone who was interested, consequently accusing anyone who even looked remotely in her direction of being either gay or bi-curious…Of course I looked…besides, it was part of my job, right?

Another time, during Spring Break, we were dispatched to a bar on the “Strip” in Fort Lauderdale referenced “unconscious person”. Upon our arrival, we were presented with a heavily mustachioed male in his early thirties lying on the floor dressed in black motorcycle boots and cap, as well as a black leather motorcycle jacket covering a pink ballet tutu. Although it was the first time I had ever encountered such an incongruous mix of clothing styles, no one in the bar seemed to pay any special notice. In fact, they were all standing around him drinking and talking as if it was the most natural thing in the world, at least at that bar. I recall they said he was a regular.

Not all of these categories are clear-cut by any means. One call in particular managed to encompass strange, bizarre, peculiar, disarming, and bloody/gory in an instant.

We were dispatched to the southeast edge of the county just south of a major interchange of three major highways that was still under construction. We were unfamiliar with the new roadways as they now involved circular on and off ramps, elevated sections, and were not especially well-marked as to exactly where you were at any given point, lacking even mile-markers, although the new exchange was just recently opened to the public only days before. The call was referenced simply “signal twenty” (psychiatric), which also became the label we used to refer to the patients we treated. Upon our arrival, we saw both Highway Patrol and County Sherriff’s Deputies standing near a naked man behind a maroon Buick Cutlass with the trunk lid open. The man was obviously distraught and sweating profusely, in spite of the fact that it was about three am in December in South Florida, or that he was unclothed. His hair was disheveled, and his gestures were exaggerated, but the look in his eyes was clearly one of a totally irrational being. When the officers got too close, he would start to become even more agitated, so as a result, one deputy stood about three feet from him as he attempted to reason with the man, as they others stood back, so as not to crowd him. The high intensity sodium vapor lights cast a sort of flamingo-pink hue down upon the scene as our stark white Halogen headlights provided an exaggerated modeling effect upon the group, like Caravaggio on acid. The pulsating red, white, and blue strobes of our combined emergency lights created a disarming final touch to this vision of one man’s personal Hell.

As we arrived, and took our stretcher out, we tried to approach the subject as unobtrusively as possible, given the bizarre scene encountered, as we did not want the patient to feel any more defensive, or become alarmed by our approach and perhaps run out into traffic. The officers involved were clearly nearly as uncomfortable as their suspect, and couldn’t wait to relinquish responsibility of this naked madman to us. Without warning, he suddenly spun around towards the trunk of the car and slammed the lid down violently as he howled a blood-curdling scream. As the cops attempted to subdue him, he spun around again several times, trying to avoid their grasp, revealing that he had indeed slammed the trunk lid down upon his penis and scrotum, inflicting a guillotine amputation which was now spurting blood from a severe arterial bleed. They reflexively jumped back, but were nonetheless soaked by the blood spray, although they quickly regained what was left of their composure enough to subdue him sufficiently to secure him to our stretcher using twisted, knotted sheets rather than handcuffs, as was our practice in those days, since he was now our patient, rather than their prisoner, and state regulations did not allow us to carry the leather restraints normally used in hospitals.

Once restrained, our treatment predominantly involved applying bulky surgical dressings to the affected areas with very firm direct pressure. The patient was in serious danger of exsanguination in a very short time without definitive treatment. Emergency treatment also involved establishing two large-bore intravenous lines running lactated Ringer’s solution at rate sufficient to maintain a viable pulse and blood pressure, and high-flow oxygen administration. Since the intravenous crystalloid fluid administration is a volume replacement only, it does effectively dilute the remaining blood supply, which is why it has to be done judiciously so as to not force out the remaining blood. Add to this the further complication that I was obligated to apply continuous pressure, and that immediate transport could not be delayed by IV administration, or that I needed to maintain the presence of mind to request the officers on scene to unlock the trunk to retrieve the amputated part before we left (which they were none too keen on touching) or the fact that we were all drenched in blood within seconds, and you can easily see why this call still remains on my top-ten list of worst calls, no matter what your criterion. To the best of my recollection, that was at least the first time I was obligated to grab (and hold) the crotch of an insane man. It would not, however be the last time, but that is another story for another time….

The most revolting call involved being dispatched reference “worms”. Upon arrival, a small boy about ten years old came out of the house. We asked if anybody had called 911. The boy nodded. We asked if they called because of worms. The boy nodded again. We asked if it was he. He nodded a third time, and then opened his mouth to reveal pinworms crawling up his esophagus and into his mouth like a handful of angel hair pasta.

Challenging and dangerous rescue operations that stand out in my mind would involve extricating a shooting victim in the middle of a riot, water rescue of a motor vehicle crash victim in shark-infested waters at night, and water rescue of a baby from the back seat of a car in a canal.

The first call was dispatched as a man down secondary to gunshot wounds. On arrival, we discovered that a half-dozen sheriff’s deputies were on scene in a vacant lot trying to disperse a mob of what looked like a hundred or so people, and a man lying face down about twenty feet away. We had no idea what was the relationship between the shooting victim and the crowd, but they were extremely agitated, and would probably have overrun the deputies, were it not for the presence of three or four canines who looked like they couldn’t wait to take a bite of fresh meat, as well as the shotguns the deputies were brandishing in a most menacing manner. We arrived in a squad unit, and our ambulance arrived separately with two EMT’s to assist.

In a situation like this, even the most basic assessment procedures will be done later. For now, the object is to “swoop and scoop” to safely remove the victim from the crime scene. There was no additional information as far as what events had precipitated the shooting, or even if the shooter was still on scene, or somewhere close enough to still represent a threat. Full trauma precautions involve spinal immobilization with a “Philly Collar”, a long spine board, and cross-strapping. In less than a minute, the four of us log-rolled the patient onto the board and carried him into the ambulance, which was parked in the middle of the lot. My partner quickly transferred our ALS gear into the ambulance via the side doors as I prepared to work the patient, assisted by one of the EMT’s who arrived with the transport unit. Everyone was very excited at this point, and unbeknown to the driver, my partner was still standing between the two open side doors. Suddenly, the driver put the unit in gear and floored it. The driver also did not realize that the right side of the unit had been parked much too close to a no parking sign, which he sideswiped, knocking the door shut, and narrowly missing my partner in the process.

The victim was in full cardiopulmonary arrest, although strangely enough, there was little blood on scene, and only two very small-caliber bullet wounds in the middle of both deltoid muscles, almost identically placed. Later X-rays revealed that one of the two wounds was an entrance wound, and the other a very non-characteristic exit wound. The bizarre part of this scenario was that the path of the bullet went from entering at the deltoid muscle, glancing off the scapula, ricocheting off the base of the skull into the first two cervical vertebrae, which it vaporized, only to finally glance downward, off the opposite scapula, and out the other deltoid muscle. This kind of injury is characteristic of the .223 caliber bullet used in the M16 assault rifle. Regardless of where the bullet enters, it can tumble and ricochet all over the body, and exit almost anywhere.

The water rescue was necessary to locate a MVC (Motor Vehicle Crash) victim who had been ejected from an eighties-era Trans-Am through the T-top. We were first on scene; it was after eleven P.M. and I was new to the area. The driver stated that his friend had been ejected into the water. There was blood everywhere on the passenger side of the vehicle. I immediately grabbed a mask, snorkel, fins and a light and went into the water. About thirty yards from the shore, I found the victim floating face down in chest-deep water. He had no skull above the eyebrow line. I brought him to shore about the time the volunteer firemen arrived. They later told me a story about a legendary hammerhead shark, a behemoth over seventeen feet long that was often known to inhabit that particular stretch of water, and had terrorized anglers and local residents alike for years.

The last rescue was referenced car in canal. On arrival, we found a Florida Power and Light employee and several bystanders trying to use one of the poles the employee had on a trailer to try to wedge it under the vehicle to prevent it from falling completely into the water. Along this stretch of road, the canals are dug into bare coral rock, with sheer walls, almost twenty feet deep, and about as wide as the length of the car. The back wheels were still on land as we arrived, but shortly afterward, the car rolled off the pole, and started to go nose-down into the water, Although the mother had jumped clear of the driver’s seat, her baby was strapped into a car seat in the back. My partner immediately jumped into the water and swam into the car as it disappeared from sight, only to surface several moments later, holding the child.

Eventually, the last subject will come up, if there is sufficient time, booze, or weed to provoke such discussion. People frequently ask it a great deal more often than you might suspect. It seems like everyone has heard of rumors about it, but no one seems to claim having personally known anyone to whom it has happened, and NO ONE EVER admits to having had to call 911 because of something they stuck up their ass, although on more than one occasion, I have suspected that it was more than just idle curiosity about an urban legend that prompted the question in the first place. “Does that really happen? Have you ever seen anything like that?” and my own personal favorite “Is that actually possible?” all tend to make me suspect that what they really want to know is “Could that actually happen to me?”

In case you are still wondering, the answer is yes. As regards softer and less dangerous objects, (like dildoes, cucumbers, and those embarrassing looking squash you see in the grocery store) the main principle is What Goes In, Must Come Out, at least eventually. Pain and fear usually provoke panic, which will produce muscle clenching enough to thwart initial removal. ER treatment is usually centered around getting the patient to relax long enough for nature to take its course, but I know of a surgical RN who has a sort of rogues’ gallery of Xerox copies of x-rays of pickle jars, bottles, a thermos, and similarly dangerous objects that did have to be surgically removed. Add the challenge of emergency extrication and what we call disentanglement if the patient has managed to squeeze the faucet from their bathtub up there while it was still attached to the wall… (and yes, that really did happen).